Herbal
Formulation Consultation Form
Instructions: Copy & paste the form below into notepad, or directly into an email, fill it out in as much detail as possible & email it to me at consultations@dragonflyherbals.com Go back to the Consultation page and send in your payment. I will email a consulation report to you within a few days. I send a lot of information back to my clients, covering changes in eating habits, supplements & herbs, it is helpful to print it & keep it for your reference or for when you go to the health food store to buy supplements. Support by email is always available, if you have questions..
NAME:
EMAIL: (MAKE SURE YOU ADD MY EMAIL TO YOUR ADDRESS LIST SO MY REPLY DOESN’T
GO TO YOUR JUNK MAIL)
PLEASE INDICATE YES, IF YOU AGREE TO THE TERMS OF MY DISCLAIMER:
MAIN HEALTH CONCERNS: PLEASE BE AS DETAILED AS POSSIBLE
NERVOUS SYSTEM:
ENERGY LEVELS:
STRESS:
SLEEP:
ANXIETY
DEPRESSION/SADNESS
SAD: SAD, CAN’T SLEEP DURING NON SUNNY MONTH
ANGER
DIGESTIVE SYSTEM EVALUATION:
NUMBER OF BOWEL MOVEMENTS PER DAY
CONSTIPATION
DIARRHEA
DIGESTIVE SYSTEM EVALUATION: PLEASE INDICATE NEXT TO EACH ITEM (NEVER
= 0, OR SOMETIMES = 1, FREQUENTLY= 2, BY PUTTING 0,1, OR 2 NEXT TO EACH
ITEM)
Section 1
1. burping
2. hiccups
3. feeling of fullness long after eating
4. bloated feeling in stomach
5. poor appetite
6. stomach upsets easily
7. history of constipation
8. food allergies
Section 2
1. Abdominal cramps
2. indigestion 1 – 3 hours after eating
3. fatigue after eating
4. lower bowel gas
5. alternating diarrhea and constipation
6. diarrhea
7. fiber causes constipation
8. mucus in stools
9. stool poorly formed
10. shiny stool
11. foul smelling stool
12. dry flaky skin and/or dry brittle hair
13. pain in left side under rib cage
14. acne
15. food allergies
16. difficulting gaining weight
Section 3
1. stomach pain
2. stomach pain just before and/or after meals
3. need for antacids or acid reducers
4. chronic abdominal pain
5. butterfly sensations in stomach
6. stomach pain when emotionally upset
7. sudden acute indigestion
8. relief of stomach pain by drinking milk or cream
9. current ulcer YES OR NO
10. black stool (not from taking iron
supplements or bismuth medications
Section 4
1. frequent recurrent infections or colds
2. bladder or kidney infections
3. vaginal yeast infection
4. abdominal cramps
5. toe or fingernail fungus
6. alternating diarrhea and constipation
7. constipation
8. history of antibiotic use
9. meat eater
Section 5
1. intolerance to greasy foods
2. yellow in whites of eyes
3. light colored stools
4. hard stools
5. sour or metallic taste in mouth
6. bad breath
7. body odor
8. fatigue and sleepiness after eating
9. frontal headaches after eating
10. pain in right side under rib cage
11. water retention
12. dry skin or hair
13. have or had gallstones
14. had jaundice or hepatitis n
15. high blood cholesterol with low LDL
16. known cholesterol above 200
17. known triglyceride level above 115
BLOOD SUGAR EVALUATION
In between meals, in the afternoon, or at night do you get any of the
following:
1. shaky
2. tired
3. irritable
4. nervous
5. cold
6. confused
7. craving sugar
8. can’t concentrate
9. exhaustion in mid afternoon
CANDIDA EVALUATION
1. ANTIBIOTIC USE
2. MUSCULAR, JOINT PAIN, STIFFNESS, WEAKNESS
3. HEADACHE
4. DEPRESSION
5. INABILITY TO CONCENTRATE
6. FATIGUE
7. INTESTINAL UPSETS
8. ACNE
9. CRAVINGS FOR SWEET FOODS, SUGAR, ALCOHOL
10. CRAVINGS FOR BREADS, PASTRIES
11. ANXIETY
12. SENSITIVITY TO PERFUMES, TOBACCO, CLEANING AISLE AT THE GROCERY STORE
13. FUNGAL INFECTIONS
14. SKIN PROBLEMS: ECZEMA, HIVES, ITCHING
15. CONSIPATION &/OR DIARRHEA
16. GAS, BLOATING
17. FORGETFULNESS
18. RESPIRATORY PROBLEMS
19. ITCHING IN EARS OR NOSE
WOMENS:
1. MENOPAUSAL: MOOD SWINGS/ANXIETY/ANGER
HOT FLASHES
NIGHT SWEATS
HEAVY BLEEDING
LEG CRAMPS
HEART PALPITATIONS
FOGGY THINKING
2. PMS
3. WATER RETENTION
4. BLADDER INFECTIONS
5. LOW IRON
6. MOOD SWINGS
7. CRAMPS
Any information
presented here is for informational purposes only and not intended to
take the place of diagnosis and treatment by a medical practitioner.